Monday Medical: Concussion management

Editor's note: A version of this article was published in December 2009.

A concussion or mild traumatic brain injury occurs when a person receives a bump or blow to the head that causes the brain to shake inside the skull. This force disrupts the way the brain typically functions and can cause a change in mental status such as loss of consciousness, amnesia, disorientation, confusion or mental fogginess.

“A concussion is often a misunderstood injury because its symptoms are not always straightforward,” said Michael Collins, Ph.D., a neuropsychologist and assistant director of the University of Pittsburgh Medical Center’s Sports Medicine Concussion Program.

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“I see daily in my clinic that no two concussions are alike, and the injury’s effects and recovery period are different in each individual,” he said.

Collins said research has shown that allowing enough healing and recovery time for the brain after a concussion is crucial in preventing further damage.

“Nationwide, we are seeing that concussions are too often under-diagnosed and poorly managed,” he said. “We are concerned about that because if a brain injury like a concussion is not diagnosed and given time to heal properly, it could lead to further injury and more serious long-term problems.”

Relying on an athlete’s self-report of symptoms is inadequate; often, athletes will hold back describing all of their symptoms in an attempt to get back to the playing field.

Athletes who return to play too soon — before their brains have healed — are likely to suffer further brain injury, including post-concussion syndrome. If another concussion occurs soon after the initial injury, this “second-impact syndrome” can have catastrophic results.

Research at the UPMC Sports Medicine Concussion Program shows that even athletes who report being symptom-free may continue to exhibit neurocognitive deficits that they are either unaware of or are failing to report.

Because of these and other findings, Collins and Mark Lovell, Ph.D. and current director of the UPMC Sports Medicine Concussion Program, have led the current re-examination of traditional return-to-play standards that primarily were symptom-based.

Traditional neurological and radiologic procedures, such as CT and MRI scans and electroencephalograms, provide important information in identifying serious concerns, including skull fracture, hematoma and confusion. However, they are not useful in identifying the effects of concussion.

In proper concussion management, it is important to have baseline neurocognitive testing as well as post-injury testing. Such evaluation can help to objectively assess the athlete’s post-injury condition and track recovery for safe return to play.

In 1999, ImPACT, or Immediate Post-Concussion and Cognitive Testing, was developed by Lovell and Joseph Maroon. It is the first and most widely used computerized sports concussion evaluation system, designed after almost 10 years of university-based, grant-supported research.

The 20-minute ImPACT test measures brain processing, speed, memory and visual motor skills. It helps to quantify the athlete’s brain’s ability to function at a normal level pre- or post-injury. This brings objectivity to managing a difficult injury.

Even what seems to be a very mild concussion needs to be taken very seriously since deficits on ImPACT can be seen several days or even weeks post-injury. Younger athletes are more vulnerable to further brain injury post-concussion and require longer recovery time than older athletes.

Collins presented to physicians, care providers and coaches on the progression of concussion care earlier this year. A new emphasis on differentiating between the types of concussion and specialization of treatment was a major focus of his education.

Physical therapist Gina Gower, a member of the concussion team at SportsMed, participated in Collins’ program.

“We can do more now to treat individual concussions, rather than just global management. It is no longer one size fits all. Our concussion care is evidence-based and specialized to the individual,” she said.

More than 900 schools, 250 colleges and universities, 125 professional sports teams and 250 sports medicine clinics nationwide now use the neurocognitive testing with ImPACT.

Locally, this pre-injury testing is available at SportsMed at Yampa Valley Medical Center, in Steamboat, Hayden, North Park and Soroco schools as well as the Steamboat Springs Winter Sports Club.

The hope is that our community of athletes, coaches, athletic trainers, physical therapists and physicians will incorporate the same diagnosis, evaluation and management of concussion injuries.

Lisa A. Bankard is director of Yampa Valley Medical Center’s Wellness and Community Education programs. She can be reached at lisa.bankard@yvmc.org.